Since its inception over four decades ago, New York State’s Medicaid program has expanded inexorably. Today it is the nation’s most expensive by far, projected to spend a mind-boggling $49.2 billion in 2010—roughly 14 percent of the nation’s total Medicaid budget, though the state holds just 7 percent of the nation’s population. The program’s enormous size has helped saddle New York taxpayers with some of the highest state and local taxes in the United States, killing jobs and siphoning support from other vital public needs.